Abstract
Objective
Although the advantages of postoperative braces have been verified in many fields, it is not clear whether postoperative braces can help reduce patients' adverse psychological emotions such as kinesiophobia, anxiety, and depression. This study aims to analyze whether the use of a postoperative brace helps reduce adverse psychological emotions in adolescent idiopathic scoliosis (AIS) patients undergoing spinal deformity surgeries.
Methods
All consecutive patients who underwent spinal corrective surgeries at our institution between April 2023 and July 2023 formed the prospective cohort. Outcome measures were collected in the preoperative period, 3 months after surgery, and 6 months after surgery. All patients were assessed using the Tampa scale for kinesiophobia (TSK), the hospital anxiety and depression scale (HADS), and the numerical rating scale (NRS). A statistical model of propensity score matching was used to eliminate potential selection bias and maintain comparability. Multivariate linear regression models were used to determine the relationship between postoperative brace and adverse psychological emotions.
Results
After propensity score matching, this study ultimately enrolled 150 patients. There were no significant differences between the two groups in terms of demographic and perioperative variables. The fully adjusted model showed that the TSK scores of the non‐brace group at the 3‐month (ꞵ = 2.50, 95% CI 0.80–4.20, p = 0.005) and 6‐month follow‐up (ꞵ = 2.75, 95% CI 0.75–4.74, p = 0.007) were significantly higher than those of the brace group. The HADS score of the non‐brace group at the 3‐month follow‐up was significantly higher than that of the brace group (ꞵ = 1.75, 95% CI 0.28–3.22, p = 0.019). The NRS score of the non‐brace group at the 3‐month follow‐up was significantly higher than that of the brace group (ꞵ = 0.69, 95% CI 0.05–1.33, p = 0.034). At the 6‐month follow‐up, there were no significant difference for HADS score or NRS score between the two groups.
Conclusion
In the early postoperative period, the postoperative brace could provide AIS patients with psychological supports and help them reduce the frequency of adverse psychological emotions. The postoperative brace could continuously improve the fear of movement within 6 months after surgery, and help reduce anxiety, depression, and pain within 3 months after surgery.
Keywords: Adolescent idiopathic scoliosis, Adverse psychological emotions, Brace, Corrective surgery, Spinal deformity
Example of postoperative brace used in this study. Wearing a postoperative brace can effectively prevent trunk excessive flexion or extension.
Introduction
Since spinal deformity surgery requires osteotomy, axial derotation, and correction, the stable structure of the spine and surrounding soft tissues will be destroyed, resulting in a decrease in spinal stability after surgery. 1 Rebuilding the stability of the spine through spontaneous or bone graft fusion takes 3–6 months or more, so protective measures during this period are particularly important. Large flexion, extension or rotation activities in the early postoperative period may increase the risk of internal fixation failure, which will further increase the patient's medical burden and time cost. 2 Based on this, some scholars recommend that patients wear a postoperative brace for at least 3 months after surgery to protect the spine from insufficient mechanical load, enhance stability, and reduce the formation of false joints. 3 , 4 , 5 In addition, psychological or proprioceptive reminders to limit unreasonable movements are another important component of the effectiveness of postoperative brace, which is particularly important in reducing the occurrence of internal fixation‐related complications. 6 However, the postoperative brace may also produce some adverse effects, including increased medical costs, muscle atrophy, and skin maceration. 7
Although the advantages of postoperative braces have been verified in many fields, it is not clear whether a postoperative brace can help reduce patients' adverse psychological emotions such as kinesiophobia, anxiety, and depression. Previous literature has demonstrated the potential impact of adverse psychological emotions on patients undergoing spine surgery, including clinical outcomes and quality of life. 8 , 9 Adverse psychological emotions such as kinesiophobia, anxiety, and depression during the perioperative period and follow‐up period would adversely affect the surgical outcomes. To make matters worse, these patients who reduce rehabilitation training due to adverse psychological emotions further exacerbate their emotional distress due to prolonged recovery time and reduced activity levels, ultimately creating a vicious cycle. 10 Therefore, measures that can effectively prevent or alleviate adverse psychological emotions in patients are important in clinical practice (Figure 1).
FIGURE 1.
Example of postoperative brace used in this study. Wearing a postoperative brace can effectively prevent trunk excessive flexion or extension.
Literature on the effects of postoperative brace on psychological status was rare, especially in the adolescent idiopathic scoliosis (AIS) patients. The vast majority of the literature treated postoperative brace as a procedure in enhanced recovery after surgery (ERAS), without discussing the impact of postoperative brace separately. Julien‐Marsollier et al. explored the clinical outcomes of patients with AIS who received the ERAS protocol. 11 The ERAS protocol included perioperative opioid‐sparing protocols, the use of a brace, and the early removal of urinary catheters. Results showed pain intensity at rest and movement were lower in the ERAS group at day 2 and 3. The study conducted by Yang et al. also proved that the use of a brace is capable of improving the perioperative status of patients with AIS by offering stronger analgesia, faster ambulation, and earlier discharge. 12
The purpose of our study was to analyze whether the use of postoperative brace helps reduce adverse psychological emotions in AIS patients undergoing spinal deformity surgeries. We hypothesized that the use of postoperative brace would be an important influencing factors of adverse psychological emotions in the early postoperative period.
Materials and Methods
Design
This prospective cohort study was conducted at our spinal deformity center, which was registered at ResearchRegistry (researchregistry9534). The study was approved by the Peking Union Medical College Hospital Institutional Review Board (K2326) and was conducted in accordance with ethical and human principles of research. On the patient's first day of admission, the research administrator would introduce the basic steps and necessary concerns of the study to the patient and family members. The investigators who performed data collection and recording during hospitalization and follow‐up were blinded to group assignment. Finally, the biostatistician responsible for the statistical analysis was blinded to group assignment and instead substituted “1” or “2” for specific information.
Participants
Patients diagnosed with AIS and undergoing posterior spinal fusion surgeries were selected to participate in the study. Other inclusion criteria included main curve magnitude of >40° and age range between 10 and 18 years old. Exclusion criteria were patients with the preoperative diagnosis of kinesiophobia, anxiety, or depression.
We conducted a preliminary study that recruited 20 patients with AIS, with 12 patients wearing a postoperative brace. The mean Tampa scale for kinesiophobia (TSK) of the two groups were 40.1 and 38.0, respectively, with an overall standard deviation of 3.2. Based on the results, we used PASS 11.0 software to calculate the sample size. With the level of significance set at 0.05 and the power at 0.95, the calculated sample size was 124. Considering the subsequent propensity score matching, the minimum sample size should therefore be 160.
Patients who underwent spinal corrective surgeries were consecutively collected between April 2023 and July 2023, and data during hospitalization and follow‐up were collected and recorded by three investigators coordinated by the study administrator. Those patients who met the inclusion criteria were fully informed and declared their willingness to comply with any treatment regimen to which they were assigned.
Surgical Procedure
All surgeries were performed by the same surgeon, the senior author, at a single institution using an identical surgical technique as described below. Patients were placed in the prone position on a radiolucent table. After a standard midline incision, subperiosteal dissection of the posterior soft tissues was performed to the tips of the transverse processes. Uniplanar pedicle screws were placed using a free hand technique bilaterally at every level in all of the patients. For some rigid curves or ones with the lowest instrumented vertebra barely touched the central sacrum vertical line, multiple‐level Ponte osteotomies were performed. After the insertion of contoured cobalt‐chromium‐molybdenum alloy rods, bilateral rod rotation and segmental derotation technique was used to correct the deformity. Under fluoroscopic control compression, distraction and in situ bending maneuvers were added if necessary. The alignment of the disc below the lowest instrumented vertebra was evaluated again with fluoroscopy. The lamina and transverse processes were thoroughly decorticated. Allograft bone material was used for fusion. Intraoperative neurophysiological monitoring was done with motor‐evoked potentials, somatosensory‐evoked potential, and electromyography.
Grouping Criteria
In this study, the presence or absence of the postoperative brace was used as the grouping criteria. Spine surgeons had no preference regarding the choice of postoperative brace. The use of postoperative brace depended on the wishes of the patients and families. At our institution, patients who wanted a customed brace required an additional customization step and manufacturing fee. Considering these additional costs and time, only some patients and families would choose postoperative braces. According to the grouping criteria, the entire study population was divided into the brace group (N = 90) and the non‐brace group (N = 75). Among the 90 patients who wore postoperative braces, 75 patients who matched the demographics and surgery‐related variables of patients who did not wear postoperative brace were selected from the cohort and used as the brace group. Patients in the brace group received a thermoplastic rigid thoraco‐lumbo‐sacral orthosis (TLSO) within the first 3 months of postoperative recovery. The TLSO covered the lumbosacral and pubic area, going up to the posterior thoracic spine (according to the upper instrumented vertebrae), and with support at the sternum to prevent anterior flexion forces. All braces were designed and manufactured at Beijing Huici Medical Biomaterials Co., Ltd. (Beijing, China). Patients were required to wear the brace regularly from the day of discharge to 3 months after surgery, and no longer wore the brace after 3 months. Spine surgeons had no requirements for how long the brace should be used. During the follow‐up period, patients were required to wear the brace as long as they have activity plans, including walking, going down stairs, rehabilitation training, and so forth. For patients in the non‐brace group, there were no special postoperative protective measures. In addition, the study administrators established contact with patients and families through timely communication software, requiring family members and other important personnel to support the patient's compliance during the study and to immediately inform staff of any difficulties or emergencies to enhance brace wearing compliance and minimize dropout rates.
Variables Measures
Outcome measures were collected in the preoperative period, 3 months after surgery, and 6 months after surgery. All patients were assessed for outcome measures using three instruments. The term kinesophobia was defined as an excessive, irrational, and crippling fear of physical movement and activity that stems from a sense of vulnerability brought on by a painful injury or reinjury. According to previous literature, kinesophobia can lead to avoidance behavior, which over time results in disability, inactivity, desperation, and a patient caught in a cycle of heightened fear of pain, worse incapacity, and further distress. Kinesophobia was assessed using the Chinese version of the TSK, ranging from 17 (best) to 68 (worst). 13 The TSK is a 17‐item self‐report scale measuring fear of movement‐related pain or injury. It uses a four‐point Likert scale with options ranging from 1 (strongly disagree) to 4 (strongly agree). After inverting the individual scores for items 4, 8, 12, and 16, the total score ranged from 17 to 68.
As the most prevalent psychological illnesses in the population, anxiety and depression disorders commonly co‐occur and considerably impact the physical and mental wellbeing of patients. The prevalence of depression and anxiety frequently correlates with physical health, and during periods of illness, adverse psychological states can hinder patients' engagement in health‐related activities. 10 The levels of anxiety or depression were assessed using the hospital anxiety and depression scale (HADS) questionnaire. This tool contains two item scales designed to assess depression and anxiety. Each question is rated on a scale of 0 (best) to 3 (worst). In this study, we used the validated Chinese version. 14 Pain was assessed using the 11‐point numerical rating scale (NRS), ranging from 0 (best) to 10 (worst). 15 Patients were asked to rate their average pain intensity while filling out the questionnaire. NRS is well‐validated in the pediatric population.
Several demographic and perioperative variables were also collected to ensure comparability between the two groups. We studied the following demographic variables: age, sex, and body mass index (BMI). The following perioperative variables were recorded: number of levels fused, number of Ponte osteotomies, main curve type, main curve magnitude, estimated blood loss, and duration of surgery. The main curve type was defined according to the location of the apical vertebra: thoracic (T2 to T11‐T12 disc), thoracolumbar (T12‐L1) and lumbar (L1‐L2 disc to L4‐L5 disc). 14
Statistical Analysis
The data of patients from the brace and non‐brace groups were put into the statistical model of propensity score matching to eliminate potential selection bias and maintain comparability between the two groups. R version 4.3.1 for Windows (R Foundation for Statistical Computing, Vienna, Austria) and R package Matchlt were used to perform one‐to‐one nearest neighbor matching without replacement and a matching tolerance of 0.2. Propensity score matching was utilized to reduce unbalanced baseline characteristics between the exposed cohort (i.e., brace group) and the non‐exposed cohort (i.e., non‐brace group). To achieve adequate statistical power, matching was conducted based on 1:1 ratio with a caliper size of 0.05 on the propensity scale. Propensity scores were calculated using a multivariable logistic regression with the following covariates: age, sex, BMI, number of levels fused, number of Ponte osteotomies, main curve type, and main curve magnitude. These covariates in the propensity score matching multivariable regression model were selected according to the previous literature and clinical experience.
Age and sex are basic demographic characteristics of the patients, and these two variables are routinely included in propensity score matching models. Cosmesis is one primary outcome of scoliosis surgery, and non‐significant improvements in self‐image may result in poor satisfaction and psychological status. Previous literature showed that BMI and degree of curve correction were the most important predictors of improvements in self‐image. 16 In addition, the degree of curve correction depends mainly on the curve magnitude, type and surgical procedures of the scoliosis surgery. Therefore, we included variables related to surgical procedures, including number of levels fused, number of Ponte osteotomies, main curve type, and main curve magnitude.
Multivariate linear regression models were used to determine the relationship between postoperative brace and adverse psychological emotions. In line with the recommendations of strengthening the reporting of observational studies in epidemiology, 17 we presented results from three models: the crude model, minimally adjusted model, and fully adjusted model simultaneously. Our criteria for selecting covariates to include in the multivariate model were as follows: first, a covariate was considered for inclusion when introducing it into the base model or removing it from the full model resulted in more than a 10% change in the regression coefficient of the independent variable. Second, we incorporated variables with a significance level of p < 0.10 in the univariate analysis. Finally, we included relevant covariates based on existing literature and clinical expertise at our institution. The significance threshold was set at 5% (p < 0.05).
Results
A total of 165 AIS patients met the inclusion and exclusion criteria. These patients were divided into the brace group (90 patients) and the non‐brace group (75 patients) according to the grouping criteria. Table 1 details the differences in baseline variables between the two groups. The results showed that the number of levels fused, number of Ponte osteotomies and duration of surgery of patients in the brace group were significantly higher than those in the non‐brace group (p < 0.05). Considering the potential selection bias of these variables on patients' psychological state, we performed propensity score matching on the data to balance the distribution of study variables in the two groups. Table 2 shows the distribution of study variables in the brace group (75 patients) and the non‐brace group (75 patients) after the propensity score matching procedure. There were no significant differences between the two groups in terms of demographic and perioperative variables (p > 0.05). The study ultimately enrolled 150 patients, with a mean age of the whole cohort of 14.4 ± 1.7 years. Most of them were female (70%).
TABLE 1.
Subject characteristics for brace group and non‐brace group before propensity score matching.
| Variables | Overall (N = 165) | Brace (N = 90) | Non‐brace (N = 75) | p‐value |
|---|---|---|---|---|
| Age, years | 14.0 ± 2.0 | 13.7 ± 2.1 | 14.3 ± 1.7 | 0.062 |
| Sex | 0.375 | |||
| Female | 113 (68.5%) | 59 (65.5%) | 54 (72.0%) | |
| Male | 52 (31.5%) | 31 (34.5%) | 21 (28.0%) | |
| BMI, kg/m2 | 19.4 ± 4.1 | 18.9 ± 4.3 | 20.1 ± 3.8 | 0.063 |
| Number of levels fused | 10.6 ± 3.3 | 11.3 ± 3.2 | 9.8 ± 3.2 | 0.006 |
| Number of Ponte osteotomies | 7.7 ± 3.5 | 8.2 ± 3.5 | 7.1 ± 3.3 | 0.036 |
| Estimated blood loss, ml | 364.8 ± 204.1 | 377.2 ± 206.1 | 350.0 ± 202.1 | 0.395 |
| Duration of surgery, min | 286.9 ± 120.3 | 303.6 ± 146.3 | 266.9 ± 74.7 | 0.050 |
| Main curve type | 0.809 | |||
| Thoracic | 32 (19.4%) | 19 (21.1%) | 13 (17.3%) | |
| Thoracolumbar | 55 (33.3%) | 30 (33.3%) | 25 (33.3%) | |
| Lumbar | 78 (47.3%) | 41 (45.6%) | 37 (49.3%) | |
| Preoperative main curve, ° | 44.9 ± 10.2 | 45.9 ± 10.3 | 43.8 ± 10.0 | 0.216 |
| Postoperative main curve, ° | 7.3 ± 3.8 | 7.0 ± 3.8 | 7.6 ± 3.8 | 0.288 |
| Preoperative TSK | 33.7 ± 10.7 | 34.3 ± 10.4 | 32.9 ± 10.9 | 0.406 |
| Preoperative HADS | 9.4 ± 2.6 | 9.5 ± 2.8 | 9.2 ± 2.4 | 0.498 |
| Preoperative NRS | 1.5 ± 1.7 | 1.5 ± 1.9 | 1.4 ± 1.3 | 0.742 |
Abbreviations: BMI, body mass index; HADS, hospital anxiety and depression scale; NRS, numerical rating scale; TSK, Tampa scale for kinesiophobia.
TABLE 2.
Subject characteristics for brace group and non‐brace group after propensity score matching.
| Variables | Overall (N = 150) | Brace (N = 75) | Non‐brace (N = 75) | p‐value |
|---|---|---|---|---|
| Age, years | 14.4 ± 1.7 | 14.5 ± 1.7 | 14.3 ± 1.7 | 0.429 |
| Sex | 0.593 | |||
| Female | 105 (70.0%) | 51 (68.0%) | 54 (72.0%) | |
| Male | 45 (30.0%) | 24 (32.0%) | 21 (28.0%) | |
| BMI, kg/m2 | 20.1 ± 3.6 | 20.0 ± 3.5 | 20.1 ± 3.8 | 0.893 |
| Number of levels fused | 9.9 ± 3.2 | 9.9 ± 3.2 | 9.8 ± 3.2 | 0.879 |
| Number of Ponte osteotomies | 6.9 ± 3.3 | 6.8 ± 3.2 | 7.1 ± 3.3 | 0.588 |
| Estimated blood loss, ml | 349.0 ± 199.1 | 348.0 ± 197.3 | 350.0 ± 202.1 | 0.951 |
| Duration of surgery, min | 275.9 ± 70.0 | 285.0 ± 64.3 | 266.9 ± 74.7 | 0.114 |
| Main curve type | 0.915 | |||
| Thoracic | 28 (18.7%) | 15 (20.0%) | 13 (17.3%) | |
| Thoracolumbar | 49 (32.7%) | 24 (32.0%) | 25 (33.3%) | |
| Lumbar | 73 (48.7%) | 36 (48.0%) | 37 (49.3%) | |
| Preoperative main curve, ° | 44.5 ± 10.1 | 45.2 ± 10.2 | 43.8 ± 10.0 | 0.431 |
| Postoperative main curve, ° | 7.7 ± 4.1 | 7.9 ± 4.3 | 7.6 ± 3.8 | 0.704 |
| Preoperative TSK | 33.9 ± 10.4 | 35.0 ± 9.8 | 32.9 ± 10.9 | 0.239 |
| Preoperative HADS | 9.0 ± 2.8 | 8.7 ± 3.1 | 9.2 ± 2.4 | 0.266 |
| Preoperative NRS | 1.5 ± 1.9 | 1.6 ± 2.3 | 1.4 ± 1.3 | 0.452 |
Abbreviations: BMI, body mass index; HADS, hospital anxiety and depression scale; NRS, numerical rating scale; TSK, Tampa scale for kinesiophobia.
When both groups were compared regarding perioperative variables, we did not find differences in: number of levels fused (mean 9.9 levels); number of Ponte osteotomies (mean 6.9 levels); estimated blood loss; duration of surgery; main curve type (mostly lumbar); preoperative and postoperative main curve. The average preoperative main curve in both groups was 45.2 ± 10.2 in the brace group and 43.8 ± 10.0 in the non‐brace group. The average postoperative main curve in both groups was 7.9 ± 4.3 in the brace group and 7.6 ± 3.8 in the non‐brace group.
Kinesiophobia
Both groups had similar preoperative TSK score (Table 3). After univariate analysis, we found that TSK score was greater at 3 months in the non‐brace group (40.7 ± 2.4 vs 38.3 ± 3.3; p < 0.001). Results were similar at 6‐month postoperative follow‐up. The TSK score of the non‐brace group was significantly higher than that of the brace group (36.8 ± 5.8 vs 33.9 ± 6.3; p = 0.004). Multivariate linear regression also verified the same conclusions (Table 4). After adjusting for age, sex, number of levels fused, number of Ponte osteotomies, main curve type, main curve magnitude, preoperative TSK, preoperative HADS, and preoperative NRS, the fully adjusted model showed that the TSK scores of the non‐brace group at the 3‐month (ꞵ = 2.50, 95% CI 0.80–4.20, p = 0.005) and 6‐month follow‐up (ꞵ = 2.75, 95% CI 0.75–4.74, p = 0.007) were significantly higher than those of the brace group.
TABLE 3.
Outcome measures of the matched brace group and non‐brace group.
| Variables | Brace (N = 75) | Non‐brace (N = 75) | p‐value |
|---|---|---|---|
| TSK | |||
| Preoperative | 35.0 ± 9.8 | 32.9 ± 10.9 | 0.239 |
| Follow up (3 months) | 38.3 ± 3.3 | 40.7 ± 2.4 | <0.001 |
| Follow up (6 months) | 33.9 ± 6.3 | 36.8 ± 5.8 | 0.004 |
| HADS | |||
| Preoperative | 8.7 ± 3.1 | 9.2 ± 2.4 | 0.266 |
| Follow up (3 months) | 13.7 ± 5.4 | 15.6 ± 3.4 | 0.013 |
| Follow up (6 months) | 11.8 ± 4.3 | 12.0 ± 4.4 | 0.780 |
| NRS | |||
| Preoperative | 1.6 ± 2.3 | 1.4 ± 1.3 | 0.452 |
| Follow up (3 months) | 1.9 ± 1.7 | 2.6 ± 2.1 | 0.034 |
| Follow up (6 months) | 0.5 ± 0.6 | 0.6 ± 0.6 | 0.446 |
Abbreviations: HADS, hospital anxiety and depression scale; NRS, numerical rating scale; TSK, Tampa scale for kinesiophobia.
TABLE 4.
Relationship between adverse psychological emotions and postoperative brace.
| Variable | Crude model a | Minimally adjusted model b | Fully adjusted model c |
|---|---|---|---|
| TSK (3 months) | |||
| Brace | Ref | Ref | Ref |
| Non‐brace | 2.40 (1.45–3.34) p = 0.001 | 2.56 (0.90–4.23) p = 0.003 | 2.50 (0.80–4.20) p = 0.005 |
| TSK (6 months) | |||
| Brace | Ref | Ref | Ref |
| Non‐brace | 2.92 (0.95–4.88) p = 0.004 | 2.94 (0.96–4.92) p = 0.004 | 2.75 (0.75–4.74) p = 0.007 |
| HADS (3 months) | |||
| Brace | Ref | Ref | Ref |
| Non‐brace | 1.88 (0.41–3.35) p = 0.013 | 1.84 (0.37–3.32) p = 0.015 | 1.75 (0.28–3.22) p = 0.019 |
| HADS (6 months) | |||
| Brace | Ref | Ref | Ref |
| Non‐brace | 0.20 (−1.21–1.61) p = 0.780 | 0.26 (−1.14–1.67) p = 0.707 | 0.29 (−1.07–1.65) p = 0.674 |
| NRS (3 months) | |||
| Brace | Ref | Ref | Ref |
| Non‐brace | 0.68 (0.05–1.30) p = 0.034 | 0.69 (0.07–1.32) p = 0.031 | 0.69 (0.05–1.33) p = 0.034 |
| NRS (6 months) | |||
| Brace | Ref | Ref | Ref |
| Non‐brace | 0.08 (−0.13–0.28) p = 0.446 | 0.08 (−0.13–0.29) p = 0.448 | 0.09 (−0.11–0.29) p = 0.402 |
Notes: Values are β (95% CI).
Crude model: we did not adjust other covariants;
Minimally adjusted model: we adjusted age and sex;
Fully adjusted model: we adjusted age, sex, number of levels fused, number of Ponte osteotomies, main curve type, main curve magnitude, preoperative TSK, preoperative HADS, and preoperative NRS.
Abbreviations: HADS, hospital anxiety and depression scale; NRS, numerical rating scale; TSK, Tampa scale for kinesiophobia.
Anxiety and Depression
Both groups had similar preoperative HADS score (Table 3). Univariate analysis showed that HADS score was significantly higher at 3‐month follow‐up when braces were not used (15.6 ± 3.4 vs 13.7 ± 5.4; p = 0.013). However, differences in HADS score disappeared at 6 months (12.0 ± 4.4 vs 11.8 ± 4.3; p = 0.780). Multivariate analysis showed the same trend (Table 4). After adjusting for age, sex, number of levels fused, number of Ponte osteotomies, main curve type, main curve magnitude, preoperative TSK, preoperative HADS, and preoperative NRS, the fully adjusted model showed that the HADS score of the non‐brace group at the 3‐month follow‐up was significantly higher than that of the brace group (ꞵ = 1.75, 95% CI 0.28–3.22, p = 0.019). At the 6‐month follow‐up, there was no significant difference in the multivariate statistical results between the two groups (ꞵ = 0.29, 95% CI −1.07 to 1.65, p = 0.674).
Postoperative Pain
Both groups had similar preoperative NRS score (Table 3). Univariate analysis showed that the NRS score was significantly higher at 3‐month follow‐up when braces were not used (2.6 ± 2.1 vs 1.9 ± 1.7; p = 0.034). Differences in NRS score disappeared at 6 months (0.6 ± 0.6 vs 0.5 ± 0.6; p = 0.446). Multivariate analysis showed the same trend (Table 4). After adjusting for potential confounding factors, the fully adjusted model showed that the NRS score of the non‐brace group at the 3‐month follow‐up was significantly higher than that of the brace group (ꞵ = 0.69, 95% CI 0.05–1.33, p = 0.034). At the 6‐month follow‐up, there was no significant difference between the two groups (ꞵ = 0.09, 95% CI −0.11 to 0.29, p = 0.402).
Discussion
Current study had found that postoperative brace could provide psychological support to AIS patients and help them reduce the occurrence of adverse psychological emotions. Postoperative brace could provide sustained improvements in the fear of movement within 6 months after surgery, and help reduce anxiety, depression, and pain within 3 months after surgery.
There has been controversy regarding the use of brace after spinal fusion surgery, with findings from the previous literature showing conflicting results. 18 , 19 , 20 Unfortunately, previous studies had not explored the relationship between postoperative brace and patients' psychological state, especially in patients with AIS. To the best of our knowledge, this study is the first in this field.
Corrective Braces and Postoperative Protective Braces
There is a difference between corrective braces and postoperative protective braces. Corrective braces are used to control the progression of primary deformity or residual postoperative deformity in patients with scoliosis, and are often accompanied by greater corrective force and longer wearing time. This type of brace is often used in the conservative treatments of scoliosis. Postoperative protective braces are designed to protect the patient from accidental injuries and relieve the patient's negative emotions. The duration of wearing is generally 2–4 months after surgery, and there is no clear standard for daily wearing time. The postoperative protective brace does not have a large corrective force and will not bring an obvious sense of pressure or restraint to the patient.
Timing and Duration of Postoperative Protective Braces
To date, the timing and duration of the use of postoperative brace is inconclusive. Some scholars recommend that patients wear the brace regularly during the day in the first 3 months after surgery, and then gradually take off the brace in the fourth month after surgery. 20 This 2–4 month wearing cycle is relatively common in the literature. The standard of our institution is that the patient wears the brace regularly for 3 months. Most studies have demonstrated the benefits of the 3‐month brace‐wearing cycle in reducing mechanical loading, promoting joint fusion, and controlling early postoperative pain. 6 , 19 , 21 Current research results show that wearing a brace can significantly reduce adverse psychological emotions within 3 months and promote patients to maintain a psychological state conducive to recovery. Surprisingly, this reduction in fear of movements persisted even after the brace was removed (3 to 6 months after surgery). Statistical analysis for 6 months after surgery showed that patients who had ever worn a brace had lower TSK score than those who had never worn a brace. This was consistent with the study conducted by Archer et al. 22 In summary, wearing a postoperative brace can continuously improve the patient's psychological state.
Adverse Psychological Emotions and Clinical Outcomes
Previous literature has demonstrated that early postoperative adverse psychological emotions predict pain, disability, and physical health after spinal fusion surgery. 22 , 23 The fear‐avoidance model suggests that patients respond to acute pain in two pathways. Pain that is not perceived as threatening does not interfere with normal movements, but pain that is perceived as threatening can heighten anxiety and cause pain‐related fear that persists during the recovery period. What is even scarier is that this fear can lead to abnormal avoidance behavior and the disuse syndrome associated with depression, thereby perpetuating the abnormal psychological state. 24 , 25 For patients undergoing lumbar discectomy surgery, patients' fear of movements is the strongest predictor of poorer quality of life and increases the risk of postoperative disability and abnormal pain. 26 , 27 Sinikallio and colleagues reported a significant association between perioperative depressive status and pain and disability at 2 years postoperatively. 28 , 29 Single and cumulative adverse psychological emotions are significantly associated with reporting of chronic pain and pain‐related disability as an adult. 30 , 31 , 32 , 33 Therefore, we have reason to believe that measures which can effectively alleviate postoperative adverse psychological emotions may be beneficial to better clinical outcomes and quality of life.
In the context of inconsistent evidence, the final decision to select a postoperative brace is often determined by preference of spine surgeons and opinions of patients, which may lead to selection bias within the patient population. To reduce the impact of the selection bias, we used propensity score matching to balance the baseline data in the two groups. This made the two groups consistent on factors other than the choice of wearing the postoperative brace. In addition, we also used a multivariate regression model to eliminate the impact of potential confounding factors on the statistical results. Therefore, we believed that the conclusions of the current study were relatively reliable.
Strengths and Limitations
This study had several strengths. First, it included a prospective large‐sample of AIS patients. This sample size allows for the detection of statistically significant associations that might be challenging to uncover in smaller studies, and it helps reduce the risk of false negatives to a certain extent. Second, this study specifically focused on AIS patients, while using propensity score matching and multivariate model to control the impacts of confounding factors.
We must acknowledge several limitations of this study. First, we were unable to detect patient compliance using information buttons or other devices, which may have led to misclassification of the brace group. This situation would dilute the difference between the two groups and lead to statistically insignificant results. However, the positive statistical results of the current study could further prove the robustness of the conclusions. Second, different medical centers and spine surgeons may have differences in their preferences for selection of postoperative braces, which may affect outcomes. However, these differences are real in clinical practice. We believe that the current real‐world study can reflect the general heterogeneity among spine surgeons, thereby enhancing the generalizability of our conclusions.
Conclusions
The use of postoperative braces could help reduce adverse psychological emotions in AIS patients undergoing spinal deformity surgeries. Specifically, fear of movement within 6 months and anxiety, depression, pain within 3 months after surgery were alleviated.
Conflict of Interest Statement
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Ethics Statement
This research was performed in accordance with the guidelines as set out by the Declaration of Helsinki. Ethical approval for the project was obtained from the Peking Union Medical College Hospital Institutional Review Board‐K2326. Informed consent was obtained from the participating patients.
Author Contributions
Ying Yang and Haoran Zhang conceived and designed the study. Xue Tian collected clinical and imaging data of the patients. Shengru Wang analyzed and interpreted the patient data. Yaping Chen and Jianguo Zhang read and approved the final manuscript.
Acknowledgments
This work was supported by the National High Level Hospital Clinical Research Funding (2022‐PUMCH‐B‐130); Peking Union Medical College Hospital, Nursing Research Funding (XHHLKY202320); Scientific Research Project of Chinese Nursing Association (ZHKYQ202106).
Ying Yang and Haoran Zhang contributed equally to this study.
Disclosure: All authors have nothing to disclose.
Contributor Information
Yaping Chen, Email: 18612672357@139.com.
Jianguo Zhang, Email: jgzhang_pumch@yahoo.com.
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